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A rest home has been criticised and three nurses referred to the Nursing Council after a patient was not given prescribed anti-clotting medication for several days and suffered a stroke.
The 89-year-old woman had been discharged from hospital to the rest home after surgery to remove a blood clot.
After the stroke, she was taken back to hospital and died several weeks later.
The cause stated on the death certificate was pneumonia following a stroke. An autopsy was not done.
In a decision made public yesterday, Deputy Health and Disability Commissioner Rae Lamb said she had recommended the Nursing Council consider reviewing the competence of the three registered nurses.
She found that one of them, and the rest home, had breached the code of patients' rights. All parties' names have been removed from the decision.
The woman developed a clot in her arm in hospital. Further clots were suspected so she was put on the anti-clotting drug warfarin.
Ms Lamb said the rest home did not correctly follow the doctor's discharge instructions and there were gaps in the warfarin treatment, despite concerns expressed repeatedly to rest home staff by the woman's daughter.
Ms Lamb attributed the drug errors to nurses not understanding or thoroughly reading all the hospital discharge information but said the rest home and the company which owns it "must share responsibility for these events".
